Skip to main content

Advertisement

SpringerLink
Log in

Three-vessel view debridement of the open tibial fracture: a surgical technique

  • Technical Note
  • Published:
European Journal of Orthopaedic Surgery & Traumatology Aims and scope Submit manuscript

Abstract

Adequate debridement of an open fracture is a key component of successful management. Despite having set debridement principles, there is no structured technique available in the literature to guide the surgeon in achieving this. We therefore present a technical note detailing the structured approach to the debridement of any open tibial fracture. Our unit has developed a novel stepwise technique termed locally as the “three-vessel view”. Identifying all three primary vessels of the leg facilitates confirmation of inspection of all lower limb compartments thus minimising the risk of missed devitalised tissue or neglected areas of contamination and the potential for consequent disastrous outcomes as a result of inadequate exposure.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

Availability of data and material

Available on request.

References

  1. Wangensteen OH, Wangensteen SD (1978) The rise of surgery: from empiric craft to scientific discipline. Published online

  2. Manring MM, Hawk A, Calhoun JH, Andersen RC (2009) Treatment of war wounds: a historical review. Clin Orthop Relat Res 467(8):2168–2191. https://doi.org/10.1007/s11999-009-0738-5

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Nuland SB (1995) Doctors: the biography of medicine. Vintage, New York

    Google Scholar 

  4. Helling TS, Daon E (1998) In flanders fields: the great war, antoine depage, and the resurgence of debridement. Ann Surg 228(2):173–181. https://doi.org/10.1097/00000658-199808000-00005

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Lister J (1867) On the antiseptic principle in the practice of surgery. Br Med J 2(351):246–248. https://doi.org/10.1136/bmj.2.351.246

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Depage A (1919) General considerations as to the treatment of war wounds. Ann Surg 69(6):575–588. https://doi.org/10.1097/00000658-191906000-00002

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Milligan ETC (1915) The early treatment of projectile wounds by excision of the damaged tissues. Br Med J 1(2843):1081. https://doi.org/10.1136/bmj.1.2843.1081

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Inter-Allied Surgical Conference, ed. General Principles guiding the Treatment of Wounds of War. Conclusions adopted by the Inter-Allied Surgical Conference held in Paris. In: Great Britian. War Office; 1917

  9. Khatod M, Botte MJ, Hoyt DB, Meyer RS, Smith JM, Akeson WH (2003) Outcomes in open tibia fractures: relationship between delay in treatment and infection. J Trauma 55(5):949–954. https://doi.org/10.1097/01.TA.0000092685.80435.63

    Article  PubMed  Google Scholar 

  10. Papakostidis C, Kanakaris NK, Pretel J, Faour O, Morell DJ, Giannoudis PV (2011) Prevalence of complications of open tibial shaft fractures stratified as per the Gustilo-Anderson classification. Injury 42(12):1408–1415. https://doi.org/10.1016/j.injury.2011.10.015

    Article  PubMed  Google Scholar 

  11. Kumar G, Narayan B (2014) Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones retrospective and prospective analyses. Class Pap Orthop 58(4):527–530. https://doi.org/10.1007/978-1-4471-5451-8_138

    Article  Google Scholar 

  12. Melvin JS, Dombroski DG, Torbert JT, Kovach SJ, Esterhai JL, Mehta S (2010) Open tibial shaft fractures: I. Evaluation and initial wound management. J Am Acad Orthop Surg 18(1):10–19. https://doi.org/10.5435/00124635-201001000-00003

    Article  PubMed  Google Scholar 

  13. Namdari S, Baldwin KD, Matuszewski P, Esterhai JL, Mehta S (2011) Delay in surgical débridement of open tibia fractures: an analysis of national practice trends. J Orthop Trauma 25(3):140–144. https://doi.org/10.1097/BOT.0b013e3181e3dff1

    Article  PubMed  Google Scholar 

  14. Hull P (2008) The management of open tibial fractures. Eur J Orthop Surg Traumatol 18(6):441–447. https://doi.org/10.1007/s00590-008-0328-3

    Article  Google Scholar 

  15. Starr AJ, Smith RM (2001) Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia (multiple letters) [5]. J Bone Jt Surg - Ser B 83(2):309. https://doi.org/10.1302/0301-620x.83b2.0830309a

    Article  CAS  Google Scholar 

  16. Naique SB, Pearse M, Nanchahal J (2006) Management of severe open tibial fractures. The need for combined orthopaedic and plastic surgical treatment in specialist centres. J Bone Jt Surg - Ser B 88(3):351–357. https://doi.org/10.1302/0301-620X.88B3.17120

    Article  CAS  Google Scholar 

  17. Giannoudis PV, Harwood PJ, Kontakis G et al (2009) Long-term quality of life in trauma patients following the full spectrum of tibial injury (fasciotomy, closed fracture, grade IIIB/IIIC open fracture and amputation). Injury 40(2):213–219. https://doi.org/10.1016/j.injury.2008.05.024

    Article  PubMed  Google Scholar 

  18. Wordsworth M, Lawton G, Nathwani D et al (2016) Improving the care of patients with severe open fractures of the tibia. Bone Jt J 98B(3):420–424. https://doi.org/10.1302/0301-620X.98B3.35818

    Article  Google Scholar 

  19. Ashall G, Moss ALH (1988) Severe open fractures of the tibia. Br Med J (Clin Res Ed) 296(6621):573–574. https://doi.org/10.1136/bmj.296.6621.573-b

    Article  CAS  Google Scholar 

  20. Lack WD, Karunakar MA, Angerame MR et al (2015) Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection. J Orthop Trauma 29(1):1–6. https://doi.org/10.1097/BOT.0000000000000262

    Article  PubMed  Google Scholar 

  21. Hertel R, Lambert SM, Müller S, Ballmer FT, Ganz R (1999) On the timing of soft-tissue reconstruction for open fractures of the lower leg. Arch Orthop Trauma Surg 119(1–2):7–12. https://doi.org/10.1007/s004020050346

    Article  CAS  PubMed  Google Scholar 

  22. Mathews JA, Ward J, Chapman TW, Khan UM, Kelly MB (2015) Single-stage orthoplastic reconstruction of Gustilo-Anderson grade III open tibial fractures greatly reduces infection rates. Injury Published online. https://doi.org/10.1016/j.injury.2015.08.027

    Article  Google Scholar 

  23. Mathews JA, Ward J, Chapman TW, Khan UM, Kelly MB (2015) Single-stage orthoplastic reconstruction of Gustilo-Anderson grade III open tibial fractures greatly reduces infection rates. Injury 46(11):2263–2266. https://doi.org/10.1016/j.injury.2015.08.027

    Article  CAS  PubMed  Google Scholar 

  24. Pollak AN, Jones AL, Castillo RC, Bosse MJ, MacKenzie EJ (2010) The relationship between time to surgical débridement and incidence of infection after open high-energy lower extremity trauma. J Bone Jt Surg - Ser A 92(1):7–15. https://doi.org/10.2106/JBJS.H.00984

    Article  Google Scholar 

  25. British Orthopaedic Association Trauma Committee (2020) British orthopaedic association standard for trauma (BOAST): open fracture management. Injury 51(2):174–177. https://doi.org/10.1016/j.injury.2019.12.034

    Article  Google Scholar 

  26. Nanchahal J, Nayagam S, Khan U, Moran C, Barrett FSS, Pallister IP (2009) BAPRAS Standards for the management of open fractures of the lower limb. Royal Society of Medicine Press Ltd, London

    Google Scholar 

  27. Marecek GS, Nicholson LT, Auran RT, Lee J (2018) Use of a defined surgical approach for the debridement of open tibia fractures. J Orthop Trauma 32(1):e1–e4. https://doi.org/10.1097/BOT.0000000000000998

    Article  PubMed  Google Scholar 

  28. Al-Hourani K, Fowler T, Whitehouse MR, Khan U, Kelly M (2019) Two-stage combined ortho-plastic management of type IIIB open diaphyseal tibial fractures requiring flap coverage: is the timing of debridement and coverage associated with outcomes? J Orthop Trauma 33(12):591–597. https://doi.org/10.1097/BOT.0000000000001562

    Article  PubMed  Google Scholar 

  29. Al-Hourani K, Stoddart M, Khan U, Riddick A, Kelly M (2019) Orthoplastic reconstruction of type IIIB open tibial fractures retaining debrided devitalized cortical segments: the Bristol experience 2014 to 2018. Bone Jt J 101(B8):1002–1008. https://doi.org/10.1302/0301-620X.101B8.BJJ-2018-1526.R2

    Article  Google Scholar 

  30. Stoddart MT, Al-Hourani K, Fowler T, Khan U, Kelly MB (2020) Plate-assisted intramedullary nailing of gustilo type IIIB open tibial diaphyseal fractures: does adjunctive plate retention affect complication rate? J Orthop Trauma 34(7):363–369. https://doi.org/10.1097/BOT.0000000000001738

    Article  PubMed  Google Scholar 

  31. Levin LS (2017) Discussion: not all Gustilo type IIIB fractures are created equal: arterial injury impacts limb salvage outcomes. Plast Reconstr Surg 140(5):1042–1043. https://doi.org/10.1097/PRS.0000000000003847

    Article  CAS  PubMed  Google Scholar 

  32. Al-Hourani K, Stoddart M, Pearce O, Riddick A, Khan U, Kelly MB (2021) Acute compartment syndrome in type IIIB open tibial shaft fractures utilising a two-stage orthoplastic approach. J Orthop Trauma. https://doi.org/10.1097/bot.0000000000002129

    Article  PubMed  Google Scholar 

  33. Crowley DJ, Kanakaris NK, Giannoudis PV (2007) Debridement and wound closure of open fractures: the impact of the time factor on infection rates. Injury 38(8):879–889. https://doi.org/10.1016/j.injury.2007.01.012

    Article  CAS  PubMed  Google Scholar 

Download references

Funding

No funding to declare.

Author information

Authors and Affiliations

  1. Department of Trauma & Orthopaedic Surgery, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, UK

    K. Al-Hourani, O. Pearce, A. Bott, A. Riddick & M. B. Kelly

  2. Department of Trauma & Orthopaedic Surgery, St George’s University Hospitals NHS Foundation Trust, London, UK

    A. Trompeter

Authors
  1. K. Al-Hourani
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. O. Pearce
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. A. Bott
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. A. Riddick
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. A. Trompeter
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. M. B. Kelly
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors provided significant contribution to the creation, analysis and editing of the following manuscript.

Corresponding author

Correspondence to O. Pearce.

Ethics declarations

Conflict of interest

A senior author on this paper (Mr Alex Trompeter) has to declare Paid services for Stryker (education and R + D) and Smith and Nephew and Orthofix (Education). No conflicts of interest relate to this work. No payments for this work. A senior author on this paper (Mr Michael Kelly) has to declare Paid services for Stryker (education and R + D). No conflicts of interest relate to this work. No payments for this work. All other Authors have no conflicts of interest to declare.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Al-Hourani, K., Pearce, O., Bott, A. et al. Three-vessel view debridement of the open tibial fracture: a surgical technique. Eur J Orthop Surg Traumatol 32, 1435–1441 (2022). https://doi.org/10.1007/s00590-021-03110-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00590-021-03110-0

Keywords

Search

Navigation